You must write AMB at the top center of the claim form!

Transcription

1 CMS 1500 (08/05) INSTRUCTIONS FOR AMBULANCE AND AIR AMBULANCE SERVICES You must write AMB at the top center of the claim form! Locator # Description Instructions Alerts 1 Medicare / Medicaid / Tricare Champus / Champva / Group Health Plan / Feca Blk Lung 1a Insured s I.D. Required -- Enter an X in the box marked Medicaid (Medicaid #). Required Enter the recipient s 13 digit Medicaid ID number exactly as it appears when checking recipient eligibility through MEVS, emevs, or REVS. You must write AMB at the top center of the Louisiana Medicaid claim form. 2 Patient s Name NOTE: The recipients 13-digit Medicaid ID number must be used to bill claims. The CCN number from the plastic ID card is NOT acceptable. The ID number must match the recipient s name in Block 2. Required Enter the recipient s last name, first name, middle initial. 3 Patient s Birth Date Situational Enter the recipient s date of birth using six (6) digits (MM DD YY). If there is only one digit in this field, precede that digit with a zero (for example, ). Sex Enter an X in the appropriate box to show the sex of the recipient. 4 Insured s Name Situational Complete correctly if the recipient has other insurance; otherwise, leave blank. 5 Patient s Address Optional Print the recipient s permanent address. 1

2 6 Patient Relationship to Insured 7 Insured s Address 8 Patient Status Optional. 9 Other Insured s Name 9a 9b Other Insured s Policy or Group Other Insured s Date of Birth Situational If recipient has no other coverage, leave blank. If there is other coverage, the state assigned 6-digit TPL carrier code is required in this block (the carrier code list can be found at under the Forms/Files link). Make sure the EOB or EOBs from other insurance(s) are attached to the claim. 9c 9d Sex Employer s Name or School Name Insurance Plan Name or Program Name 10 Is Patient s Condition Related To: 11 Insured s Policy Group or FECA 11a Insured s Date of Birth 11b Sex Employer s Name or School Name 2

3 11c 11d Insurance Plan Name or Program Name Is There Another Health Benefit Plan? 12 Patient s or Authorized Person s Signature (Release of Records) 13 Patient s or Authorized Person s Signature (Payment) 14 Date of Current Illness / Injury / Pregnancy 15 If Patient Has Had Same or Similar Illness Give First Date 16 Dates Patient Unable to Work in Current Occupation Situational Obtain signature if Optional. Optional. Optional. 17 Name of Referring Provider or Other Source 17a Unlabelled Situational If the recipient is linked to a Primary Care Physician, the 7-digit PCP referral authorization number is required to be entered. The PCP s 7-digit referral authorization number must be entered in block 17a. 17b NPI Optional. The revised form accommodates the entry of the referring provider s NPI. Enter the CommunityCARE PCP s NPI. 3

4 18 Hospitalization Dates Related to Current Services 19 Reserved for Local Use 20 Outside Lab? 21 Diagnosis or Nature of Illness or Injury 22 Medicaid Resubmission Code Required -- Enter the most current ICD-9 numeric diagnosis code and, if desired, narrative description. Situational. If filing an adjustment or void, enter an A for an adjustment or a V for a void as appropriate AND one of the appropriate reason codes for the adjustment or void in the Code portion of this field. Enter the internal control number from the paid claim line as it appears on the remittance advice in the Original Ref. No. portion of this field. Appropriate reason codes follow: To adjust or void more than one claim line on a claim, a separate form is required for each claim line since each line has a different internal control number. Adjustments 01 = Third Party Liability Recovery 02 = Provider Correction 03 = Fiscal Agent Error 90 = State Office Use Only Recovery 99 = Other 23 Prior Authorization Voids 10 = Claim Paid for Wrong Recipient 11 = Claim Paid for Wrong Provider 00 = Other If the services being billed are Air Ambulance and must be Prior Authorized, the PA number is required to be entered. Air Ambulance Services must be Prior Authorized and the 9-digit PA number must be entered in this field. 4

5 24 Supplemental Information 24A Date(s) of Service Required -- Enter the date of service for each procedure. 24B Place of Service 24C EMG Either six-digit (MM DD YY) or eightdigit (MM DD YYYY) format is acceptable. Required Enter type of service: 9 or Y Emergency 3 or N Non-emergency Providers may enter a 9 or Y for emergency services and a 3 or N for nonservices. emergency Failure to enter an indicator will default to nonemergency. 24D Procedures, Services, or Supplies 24E Diagnosis Pointer 24F $Charges Required -- Enter the procedure code(s) for services rendered in the un-shaded area(s). Enter the appropriate modifier if applicable. Required -- Enter usual and customary charges for the service rendered. 5

6 24G Days or Units Required -- Enter the number of units billed for the procedure code entered on the same line in 24D or the one-way mileage as applicable. Ensure that the appropriate units are entered for the service (i.e., 1 unit for transport and the number of miles for mileage). 24H EPSDT Family Plan 24I I.D. Qual. Optional. If possible, leave blank for Louisiana Medicaid billing. 24J Rendering Provider I.D. # 25 Federal Tax I.D. 26 Patient s Account No. 27 Accept Assignment? 28 Total Charge Optional. Situational Enter the provider specific identifier assigned to the recipient. This number will appear on the Remittance Advice (RA). It may consist of letters and/or numbers and may be a maximum of 20 characters. Optional. Claim filing acknowledges acceptance of Medicaid assignment. Required Enter the total of all charges listed on the claim. The revised form accommodates the entry of I.D. Qual. 29 Amount Paid Situational If TPL applies and block 9A is completed, enter the amount paid by the primary payor. Enter 0 if the third party did not pay. If TPL does not apply to the claim, leave blank. 6

7 30 Balance Due Situational Enter the amount due after third party payment has been subtracted from the billed charges if payment has been made by a third party insurer. 31 Signature of Physician or Supplier Including Degrees or Credentials Required -- The claim form MUST be signed. The practitioner or the practitioner s authorized representative must sign the form. Signature stamps or computergenerated signatures are acceptable, but must be initialed by the practitioner or authorized representative. If this signature does not have original initials, the claim will be returned unprocessed. Date 32 Service Facility Location Information Required -- Enter the date of the signature. Required Enter: 32a NPI 32b Unlabelled 33 Billing Provider Info & Ph # The complete address of origin of services. The time of departure from origin. The complete address of destination. The time of arrival at destination. Required -- Enter the provider name, address including zip code and telephone number. Enter the complete address of the origin of services, the time of departure from origin (including a.m. or p.m.), the complete address of destination, and the time of arrival at destination (including a.m. or p.m.) 33a NPI Optional. The revised form accommodates the entry of the Billing Provider s NPI. 7

8 33b Unlabelled Required Enter the billing provider s 7-digit Medicaid ID number. Formerly entered in Block 9 of the Unisys 105 Claim Form. The 7- digit Medicaid Provider must appear on paper claims. 8

9 SAMPLE AMBULANCE CLAIM FORM 9